http://www.washingtonpost.com/wp-dyn/articles/A24828-2001Dec25.html
Some
Want Smallpox Shots Now
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By Ceci Connolly
Washington Post Staff Writer
Wednesday, December 26, 2001; Page A01
Sen. Arlen Specter (R-Pa.) wants his four granddaughters inoculated. State
health commissioners and a newly formed Maryland parents group are pressuring
federal officials for vaccine. And at Acambis Inc., the British company chosen
to make 209 million doses for the federal government, operators are fielding
dozens of requests for a product that has not yet been licensed.
In the same way that Cipro became the drug of choice for assuaging anthrax
fears, the American public is homing in on this vaccine as the balm for
smallpox anxiety. But the Bush administration, citing limited supplies and
possibly dangerous side effects, has adamantly refused to release vaccine.
Federal officials plan to stockpile a dose for every American and dip into the
supply only if an outbreak occurs.
Veteran public health experts see a major national debate in the making that
touches on individual rights, societal responsibilities, medicine, politics and
international intelligence-gathering.
"This is a societal question," said Anthony S. Fauci, director of
the National Institute of Allergy and Infectious Diseases. "We need to
have a national discussion about what the risks are -- of an attack and of the
vaccine -- and then make the appropriate decisions."
Although smallpox was believed eradicated worldwide by 1980, its highly
contagious nature, 30 percent mortality rate and the suspicion that a rogue
nation or terrorist organization may possess the deadly virus have renewed
fears about the disease.
"Of all the agents that could be used, this is the one that worries
public health the most," said Fred Edgar Thompson Jr., Mississippi state
health officer. Thompson and the Association of State and Territorial Health
Officials have been aggressively lobbying for immediate vaccination of teams of
emergency medical personnel in each state.
Local physicians, most of whom have never seen smallpox or administered the
vaccine, say they do not want to wait until an attack to take precautions.
"If you do not vaccinate the first responders, we're going to be the
first to go," said Marjorie Barnett, a Silver Spring pediatrician. Given
today's mobile society and what she characterized as the government's slow and
confused handling of the anthrax attacks, Barnett said many doctors and
patients prefer to decide themselves.
Some of her clients have assembled a new advocacy group to lobby the Bush
administration and Congress for access to the vaccine.
"A lot of parents may not choose to have children immunized but they
would like to have the option," said Retha Oliver-Steen, a Bowie resident
who wants to have her 7-year-old daughter vaccinated. "I know there are
risks. I also know the risks of actually contracting smallpox. I don't want my
child bleeding out and suffering so much she can't even lay on the
sheets."
Even conservative analysts such as Veronique de Rugy at the Cato Institute
and Henry I. Miller of the Hoover Institution argue on libertarian grounds that
the government should not dictate who receives a vaccine when.
If made available now, "people could actually talk with their doctors
about it and have time to evaluate the risks," de Rugy said. "A
vaccinated population is not very attractive to a terrorist."
Although he would "certainly urge people not to take it," Miller
nevertheless said: "If we permit consumers to buy herbal dietary
supplements with no known benefits and many side effects, we should arguably do
the same thing for the smallpox vaccine."
Yet both acknowledge that the risks -- to the individual and perhaps others
-- are significant.
Vaccinating the entire country would probably result in 600 to 1,000 deaths,
said Steven Black, a director of the Kaiser Permanente Vaccine Study Center in
Oakland, Calif. Several thousand people would likely contract encephalitis, an
inflammation of the brain; others would develop a rash.
"We have no idea what the vaccine would do to people at the extremes of
life -- less than 2 and older than 65," said Roger J. Pomerantz, chief of
the infectious disease department at Thomas Jefferson University in
Philadelphia. An even greater concern would be the effect on people with weakened
immune systems from HIV infection, chemotherapy or transplants, he said.
Because the vaccine is a live virus, it can be transmitted from one person
to another. That poses a particular problem in hospitals where workers come
into contact with immune-compromised patients, said D.A. Henderson, director of
the newly created federal Office of Health Preparedness and leader of the
eradication effort in the 1970s.
In the days when vaccination was common, "we took people off work for
the roughly two weeks it takes for a scab to form over," he said.
Although Henderson pushed hard to expand the vaccine stockpile, he has also
argued against inoculating anyone beyond the approximately 100 lab and
emergency response personnel at the Centers for Disease Control and Prevention
deemed at high risk.
His most immediate concern is conserving the existing supply, 15.4 million
doses of old vaccine kept in 100-dose vials in a warehouse in Pennsylvania.
"If you wanted to use that vaccine for a few people here and a few people
there, you would waste a lot of vaccine," he said.
Over the long term, Henderson said the issue should be resolved by weighing
the risks of vaccination against the risks of exposure.
"The likelihood smallpox is going to be released is very low; much less
likely than anthrax or other agents," Henderson said. "It is hard to
get a hold of, hard to work with and hard to disseminate." In addition,
vaccine administered within three or four days of exposure should be adequate
protection, he said.
But that assumes rapid diagnosis of an unfamiliar illness. Edward Taubman,
an Olney internist, said it took days to get guidance from the CDC on a
possible anthrax case. "I didn't feel I got any backup from the federal
government," he said. "If my experience with anthrax means anything,
who is going to help me diagnose smallpox?"
If health care workers did not immediately spot smallpox, they and others
would be in danger of catching and spreading the disease.
"Medical professionals who understand the risks should be given the
option of being vaccinated," Taubman said.
It is possible to offer the vaccine to a wider group of people and minimize
the risk, primarily by screening for HIV or other factors that weaken the
immune system, Pomerantz said. Although the science is inconclusive on whether
adults vaccinated decades ago would retain any immunity, Fauci said people who
did not suffer side effects then should expect the same result.
Once the government has built up its stockpile in late 2002, Henderson and
other officials say they can revisit the question of pre-vaccination. But
political pressure may force quicker action.
"We can't wait that long," said Thompson of Mississippi. "We
need to use the existing vaccine."
During a recent congressional hearing, Specter said it is the federal
government's role to buy the vaccine, not to decide who may receive it.
"It's one in a million that they're going to have an adverse
reaction," he said, explaining why he wants his family vaccinated.
"You tell us what the risks are and get us the vaccine and let's leave it
up to the American people to make their choice."
Fauci agreed: "Myself personally, my own children, I would take the
risk of getting them vaccinated."
© 2001
The Washington Post Company
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